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SSI and SSDI Basics Linda Landry, Esq. Svetlana Uimenkova, Esq. Disability Law Center Basic Benefits 2011 1 Sources Of Law, Policy, & Procedure Most available online at www.socialsecurity.gov other materials at www.masslegalservices.org. United States Code (U.S.C.). Contains the federal statutes that created the SSI (42 U.S.C. §1381 et. seq.) and SSDI (42 U.S.C. §402 et. seq.) programs. Code of Federal Regulations (C.F.R.). Contains the federal regulations implementing for the SSI (20 C.F.R. § 416 et seq.) and SSDI (20 C.F.R. § 404 et.seq.) Programs. 2 Sources Of Law, Policy, & Procedure Case law. Decisions of the Federal District Courts, U.S. Circuit Courts of Appeals, and the U.S. Supreme Court. Social Security Rulings (SSR). Statements of policy and interpretations adopted by SSA based on federal court and administrative decisions, policy statements, and opinions of SSA’s Office of General Counsel. Rulings are published in the Federal Register and are binding on all components of SSA, although they do not have the force of law. Acquiescence Rulings explain how SSA will apply decisions of the U.S. Circuit Courts of Appeals that are at odds with SSA’s national policies. 3 Sources Of Law, Policy, & Procedure Program Operations Manual System (POMS). The POMS provides guidelines for day-to-day operations in SSA’s district offices and at Disability Determination Services (DDS). The POMS does not have the force of law and cannot be used where it conflicts with the statute or regulations. Hearings, Appeals and Litigation Law Manual (HALLEX). Published by the SSA Office of Hearings and Appeals (OHA), the HALLEX conveys guiding principles to OHA staff, defines procedures for carrying out policy, and provides guidance for processing and adjudicating claims at the ALJ hearing, Appeals Council, and federal court levels. 4 The Players SSA District Offices (DO) - claims representatives take applications and appeals, make decisions on non-disability issues. Disability Determination Services (DDS) - state agency under contract with SSA - lay disability examiners and DDS doctors develop evidence and make the disability determination. MA DDS is part of Mass. Rehabilitation Commission. Office of Disability Adjudication and Review (ODAR) - Administrative Law Judges. Boston & Springfield. Appeals Council – In Falls Church, VA. There are 10 Regional offices which oversee the District Offices. Massachusetts is in Region I. 5 What is SSDI? (Social Security Disability Insurance) SSDI is a Social Security insurance program that pays a monthly cash benefit to people who are: Disabled = same definition of disability as with SSI (for adults), AND Insured = worked and earned enough Social Security credits by paying FICA taxes. For most adults, this means working for about 5 of the last 10 years before becoming disabled. SSDI is not “needs-based and has no income or asset limits. 6 Earning Credits to Become Insured for SSDI Earn 1 credit for every $1120 earned in 2011 - $4480 earned = 4 credits. 1 credit- $1,130 in 2012 up to $4520/year Maximum of 4 credits/year. Must pay FICA taxes. No credits for “under the table” work. Special SSDI Rule for Young Adults: To be insured for SSDI, adults under 24 years old only need to earn 6 credits in the 3 years before they become disabled. 7 Social Security Insurance Benefits Overview Retirement Insurance Benefits (RSI) available to insured workers at retirement age. Dependents and Survivors benefits are available to certain close relatives of insured deceased wage earners or of insured wage earners eligible for SSDI or RSI. Social Security Insurance benefits sometimes called Title II benefits. 8 SSDI – Overview Continued Medicare will provide health care coverage to retired workers upon retirement. Disabled beneficiaries will begin Medicare coverage in month 25 of SSDI eligibility. People with ALS or end stage renal disease do not have to wait for Medicare coverage. 9 SSDI – Overview Continued Monthly benefit payment, called Primary Insurance Amount (PIA), is dependent on work and wage history and is unique to each worker. The maximum benefit paid in 2011 is $2323 per month. Dependent’s benefits totaling up to approximately 50% of the worker’s insurance payment will be paid to the eligible dependents. “Family Maximum” limits total payments. 10 SSDI – Overview Continued Benefits are payable, after application is filed, beginning 5 months after the “onset date,” but not more than 1 year prior to the date of application. Since December 1, 1996, must have “lawful presence” status to receive SSDI. 11 What is SSI? (Supplemental Security Income) Called SSI or Title XVI. “Needs-based” Categorical Eligibility – Aged, Blind, Disabled. Low income – Countable income less than the maximum SSI payable to that individual. Low Resources – Countable resources of less than $2000 for an individual and $3000 for a married couple. 12 SSI Eligibility - Overview Residence in U.S. for 30 days. Citizen and/or alien status requirements for benefits payable after December 1, 1996. 13 SSI - Overview Continued SSI pays a monthly cash benefit depending upon the recipient’s categorical status and living arrangement. The maximum monthly payment is set each January by the Social Security Administration. Benefit Amount is determined by deducting countable income from maximum payment for category and living arrangement. 14 SSI - Overview Continued Earliest possible payment date is the first of the month after the month of application. Medicaid (MassHealth) coverage is awarded automatically upon the award of disability and payment status. 15 SSI Basics - Income Income = “anything you receive in cash or in kind that you can use to meet your needs for food and shelter.” Income generally counted month of receipt. Counted towards asset limit if retained in subsequent month. 16 SSI Income Rules Types of Income: Earned = from employment (favored) Unearned = from other sources, e.g., SSDI, alimony, pension, inheritance Deeming = counting portion of someone else’s (parent, spouse, sponsor) income as SSI recipient’s. In-kind = shelter or food received free or at reduced cost. (capped at 1/3 FBR) 17 Examples of Income That Does Not Count Income tax refunds Loans (spent in month received) Bills paid by 3rd parties for things other than food and shelter Federal student assistance, including work-study and Pell grants Gifts of domestic airline tickets EITC and Child Tax Credit payments 18 Examples of Unearned Income Annuities, pensions, and other periodic payments, incl. SSDI and Unemployment Alimony, child support (1/3 excluded for kids under age 18) Dividends, interest Gifts, prizes Rental income Inheritances Deemed income 19 Unearned Income Exclusions Only a $20 general exclusion is applied to total unearned income Certain types of unearned income cary their own exclusions: Gross rental income may be reduced by expenses needed to earn it Deemed income reduced by exclusions included in deeming formulas 20 Not All Unearned Income is Counted Examples: Free medical care and services Income used to replace a resource (e.g., insurance proceeds) Income tax refunds Proceeds of a loan 21 More Unearned Income Exclusions Bills paid for the recipient – IF paid directly to the vendor – for non food/shelter related items Replacement of income lost or stolen Housing assistance such as public housing of Section 8 voucher 22 Earned Income Income from work is treated more favorably than unearned income. Earned income includes: Wages Net self employment income In-kind payment (e.g., free rent for work) Royalties and honoraria 23 SSI and Work – Effect of Wages For SSI, gross monthly wages count when paid/received. 20 CFR 416.1111(a). To compute countable monthly wages, deduct $65 plus ½ of the remainder from gross monthly wages. 20 CFR 416.1112(c)(5) & (7). SSI recipients may also deduct the $20 “general income disregard” from wages, if not used on “unearned” income. 20 CFR 416.1112(c)(4). A good estimate of countable wages is ½ of gross monthly wages. 24 SSI and Work – Effect of Wages Example 1 Carmen receives $788.39 in SSI disability benefits in 2011. She has no other income. She decides to take a job paying $885 in gross wages per month. What will be the effect on her SSI? 25 SSI and Work – Effect of Wages Example 1 $400 of Carmen’s gross monthly wages is countable [$885 – 85 ($65 + $20) divided by 2 = $400]. Carmen’s SSI benefit will be $388.39 ($788.39 - $400 = $388.39). Her total gross monthly income will be $1273.39 ($885 + 388.39). 26 SSI and Work – Effect of Wages Example 2 Joe receives $520 in SSDI and $288.39 in SSI disability benefits per month in 2011. He also takes a job paying $885 per month in gross wages. These wages make him SSI ineligible. 27 SSI and Work – Effect of Wages Example 2 $520 SSDI - $20 = $500 countable SSDI $885 gross wages - $65 = $820. $820 divided by 2 = $410 countable wages. $500 + $410 = $910, more than the SSI amount ($288.39) for which Joe is eligible. Joe’s total gross monthly income is $1405 ($520 + $885). Will Joe remain eligible for MassHealth? Probably. 28 SSI Benefits and Work Self Employment Income SSA starts with net self employment to calculate the amount of SSI the individual would otherwise be eligible to receive. 20 CFR 416.110(b), 416.1111(6). 29 SSI Benefits and Work IRWE Deductions Impairment Related Work Expenses (IRWEs) may be deducted to determine countable gross monthly wages and countable net self-employment income. 20 C.F.R. 416.1112 IRWE deductions are in addition other permitted earned income deductions 30 SSI Benefits and Work IRWE Deductions IRWEs are: impairment related items and services needed in order to work out of pocket, i.e., paid by the individual and not reimbursed by any source. paid in a month when individual worked. 20 CFR 416.976 31 IRWE Examples Attendant care services provided at work or at home to prepare for work. Transportation costs required by disability. Durable medical equipment. Service or support animal costs 32 IRWE Examples Residential modifications to permit access, if employed outside the home If self-employed, modifications to create an interior workspace Medications/treatment necessary to control a condition to permit work. Non-medical equipment where necessary to control a condition, e.g., air conditioner for respiratory condition. 33 SSI Benefits and Work BWE Deductions Blind Work Expense (BWE) deductions are available to SSI recipients eligible on the basis of blindness. BWEs are in addition to other permitted earned income deductions. 20 CFR 416.1112(c)(8). 34 SSI Benefits and Work BWE Deductions Examples of BWEs (POMS SI 00820.555): service animal expenses; transportation to and from work; taxes; attendant care services; visual aids; translation of materials into Braille; lunches; professional association dues. 35 Work SSI and SSI Benefits Student Earned Income Deduction The student earned income deduction is for SSI recipients who: are under age 22, and are regularly attending school. 20 CFR 416.1112(c)(3). 36 Work SSI and SSI Benefits Student Earned Income Deduction Regularly attending school means: For grades 7-12, attending at least 12 hrs per week; For college or vocational program, attending at least 8 hrs per week. 20 CFR 416.1861 37 SSI Benefits and Work Student Earned Income Deduction In 2011, the student earned income deduction is $1640 per month, up to a maximum of $6600 per year. This amount is indexed to the yearly cost of living increase. This deduction is in addition to other permitted earned income deductions. 38 Federal Educational Assistance All student financial assistance received under Title IV of the Higher Education Act of 1965, or under BIA Student Assistance Programs, is excluded from income and resources, regardless of use. Title IV programs include: Pell Grants; federal work study programs; Upward Bound, and others specified in POMS SI 00830.455. 39 Other Educational Assistance any portion of a grant, scholarship, or fellowship used for paying tuition, fees, or other necessary education expenses is not countable income. 20 CFR 416.1124(c)(3). any grant scholarship, fellowship, or gift for the cost of tuition or fees does not count as a resource for nine months. 20 CFR 416.1210(u), 416.1250. 40 Plan to Achieve Self-Support (PASS) Set aside income and resources to use to achieve an occupational goal. Occupational goal must be feasible. PASS must be in writing and include budget (& business plan if self-employment). If PASS is approved by SSA & followed, income and resources in PASS don’t count for SSI. 20 CFR 416.1112(c)(9), 416.1210(f). 41 Resources SSI limits the amount of countable resources an SSI recipient can own. An individual recipient can hold only $2000 in countable resources. A married couple can hold only $3000 in countable resources. 42 Resources A resource is cash on hand, other personal property, or real property that an individual: owns or has an ownership interest in; has the legal right to dispose of and convert to cash; and is not legally restricted from using for support Income remaining after the month received becomes a resource. 20 C.F.R. 416.1201 43 Examples of Excluded Resources The home that the individual lives in. Household goods and personal effects. An automobile of any value if used for work or medical appointments/services. Retroactive SSI/SSDI for 9 months. Earned Income Tax Credit for 9 mos. Federal student aid, including work-study. 44 Excluded Resources PASS protected income and resources Income producing property (PESS) (limited to $6000) Whole life insurance (face value less than $1500) Burial funds (up to $1500) Burial spaces (unlimited value) 45 Transfer Of Assets Any resource that is transferred for less than fair market value will result in a “transfer of assets penalty” causing ineligibility for a maximum of 36 months. 20 C.F.R. 416.1246 46 Non-Citizen SSI Eligibility Criteria Prior to 8/26/96 PRUCOL (Permanently Residing Under Color of Law) was the standard. Now eligibility is much more limited. Eligibility depends on the immigrant’s status and date of entry into the U.S. Three basic groups of aliens. 47 (1) Noncitizens Receiving SSI on 8/22/96 All noncitizens who were "receiving" SSI on 8/22/96 are "grandfathered" into the SSI program, as long as they meet at least PRUCOL and remain otherwise eligible. 48 (2) Noncitizens Who Entered Prior to 8/22/96 Eligible for SSI IF they: were "lawfully residing" on 8/22/96; AND are now "qualified aliens;" AND are now "disabled" or blind (regardless of age) POMS SI 00502.142 49 Definition of “Qualified Aliens” "QUALIFIED ALIENS" include legal permanent residents (including Amerasians), asylees, refugees, persons granted withholding of deportation (now called cancellation of removal), Cuban/Haitian entrants, persons granted parole status for a period of at least 1 year, and battered spouses with a pending or approved spousal visa or petition for relief under VAWA and whose need for benefits has a substantial connection to the battering and who no longer live with their batters. 50 Definition of “Lawfully Residing” A U.S. Resident = establishes residency in the U.S. with the intent to continue living within the geographic limits of the U.S., AND “Lawfully Present" = inspected & admitted to U.S. & no violation of terms of admission. Includes most legal nonimmigrants. POMS SI 00502.142B.2 51 (3) Non-Citizens who Enter After 8/22/96 Must meet one of the following to be SSI eligible: LPRs, BUT only those with 40 quarters of coverage AND after 5 years in the U.S.; OR refugees, asylees and persons granted withholding of deportation, BUT ONLY for the FIRST 7 YEARS in those statuses; OR honorably discharged veterans and active duty armed services personnel who are "qualified aliens" and their spouses and unmarried, dependent children. 52 “Fleeing Felon” Rule Effective 8/22/96, ineligible for SSI if: fleeing to avoid prosecution for a crime, or an attempt to commit a crime, which is a felony; fleeing to avoid custody or confinement after conviction for a crime, or an attempt to commit a crime, which is a felony; violating a condition of probation or parole imposed under federal or state law. 53 “Fleeing Felon” Rule – Cont. Extended to SSDI, effective 1/1/05. Appealable; aid pending appeal possible. Advocacy issues: Intent – e.g., person who doesn’t know about warrant can’t have intent to flee to avoid prosecution. Limited Good Cause criteria Factual errors – e.g., SSA relied on incorrect info from law enforcement. Contact public defender in state where warrant issued. 54 Martinez Class Settlement Martinez et al v. Astrue. No further suspensions for warrants other than those issued for flight or escape (codes 4901, 4902, 4999). Varying relief for class members. Does not apply to warrants for probation or parole violations. More information: www.NSCLC.org, www.masslegalservices.org 55 Clark Class Settlement Clark et al v. Astrue, settlement in the works Eff. 5/9/11, no further benefit suspensions based solely on outstanding probation or parole warrants Stay tuned for details on class relief More information: www.NSCLC.org. www.masslegalservices.org 56 Definition of Disability for Adults 20 CFR 416.905 The inability to engage in any substantial gainful activity (SGA) by reason of medically determinable physical and/or mental impairment(s) which can be expected to last for a continuous period of not less than 12 months or result in death. 57 5-Step Sequential Analysis 20 CFR 416.920 STEP 1. Is the applicant engaging in Substantial Gainful Activity (SGA)? STEP 2. Does the applicant have a severe impairment? STEP 3. Does the applicant suffer from an impairment which meets or equals the severity of a listed impairment? 58 5-Steps - Continued STEP 4. Does claimant have the residual functional capacity (RFC) to perform his/her past relevant work (work performed in the last 15 years)? STEP 5. Does the claimant have the RFC to perform any other work that exists in significant numbers in the national economy? Burden of proof shifts to SSA at step 5. 59 Step 1 - Substantial Gainful Activity (SGA) Substantial = perform significant physical or mental duties productive in nature. Gainful = work usually done for pay or profit, whether or not it's realized. Significant duties = have a degree of economic value. Work performed in one's own household tasks, and non-paying work on hobbies, training, school, clubs, social programs, etc. does not = SGA in and of itself. 20 CFR 416.974 - .976 60 SGA (cont.) Look at average gross monthly earnings. If countable gross earnings go over threshold, SGA is presumed. Part-time work can be SGA. SGA threshold changes every year. In 2011, SGA threshold is $1000 gross/month. In 2012, SGA is $1,010 gross/month. SGA threshold for blind SSDI applicants in 2011 is $1640. No SGA test for blind SSI applicants at application. 2012 SGA-$1,690. If self-employed, look at net income after business deductions; value of work to business. 61 There’s More to SGA than the Numbers Unsuccessful Work Attempts (UWA) are not SGA. UWA if work stops or earnings go below SGA due to impairment or removal of special conditions within 3 - 6 months. Countable earnings may be reduced: Subsidies and special conditions, and Impairment Related Work Expenses 62 Step 2 – Severity 20 CFR 416.921 - .923 Not severe = a slight abnormality that would have no more than a minimal effect on an individual’s ability to work even if he or she were of advanced age, had minimal education, and limited work experience. McDonald v. Sec’y HHS, 795 F.2d 1118 (1st Cir. 1986). SSR 96-3p 63 Step 2 – Severity – cont’d “Severity” test is de minimis test All impairments must be considered in combination to determine whether the severity test is met – regardless of whether any impairment considered alone is severe. 64 Step 3 – Listing of Impairments 20 CFR Appendix 1 to Subpart P of Part 404. 14 body systems. Medical criteria described that presume functional limitations that preclude work. If medical documentation that impairments meet or equal these criteria, disability finding required. No vocational analysis. 65 Step 3 – Listing of Impairments – cont’d Medical listings serve to screen in the most severe impairments Medical criteria presume functional limitations that prevent work Medical documentation of the listed criteria = allowance, without individual consideration of functional limitations – except for mental impairments 20 CFR 416.925 - .926 66 Step 3 - Proving Claimant Meets or Equals a Listing Medical records from acceptable medical source. Narrative letter or detailed, listing-based form from doctor. Conclusions must be supported by medical findings in records. Psychiatrist & therapist can co-sign. Send letter to doctor requesting letter, include copy of the listings for guidance. Follow up with phone call. 67 Step 4 – Evidence Issues 20 CFR 416.960(b), .965(a) Given medically determinable impairments, does claimant have the RFC (Residual Functional Capacity) to return to past relevant work? PRW = work performed at SGA level in 15 years before onset of disability. Compare skill, strength requirements of past work with current RFC. Claimant has burden to prove. Don’t forget this step at hearing, even if DDS determined that claimant could not do past work. 68 Step 4 - Continued If past work done in foreign country, issue is whether claimant could perform work as it was done there. Language issue, lack of U.S. equivalent irrelevant. SSR 82-40 Irrelevant that past work is now obsolete. Barnhart v. Thomas, 540 U.S. 20, 124 S.Ct. 376 (2003). Ability to return to past part-time SGA level work = not disabled. 69 Residual Functional Capacity (RFC) 20 CFR 416.945 Maximum ability to do sustained work-related physical and mental activities in a work setting, on a regular and continuing basis, despite limitations caused by their impairment(s) and related symptoms. See SSRs 96-8p, 96-9p. “Regular and continuing basis” means 8 hours/day 5 days/week or equivalent. Must consider total limiting effects of all impairments, even non-severe ones and all relevant evidence in the record. Based on medical evidence and other evidence re: functional limitations. 70 Physical RFC Components 20 CFR 416.945(b) Exertional limitations: Standing, sitting, walking Alternating sitting and standing Lifting Pushing, pulling Postural limitations Balancing Climbing Stooping, bending, kneeling, crouching, crawling 71 Physical RFC Components – cont’d Manipulative limitations Reaching Handling (gross manipulation) Fingering (fine manipulation) Feeling (skin receptors) Visual limitations Communicative limitations Speaking, hearing 72 Physical RFC Components – cont’d – 20 CFR 416.945(d) Environmental limitations Cold, heat Wetness, humidity Dust Noise Vibrations Fumes, odors Heights 73 Measuring Physical RFC Occasionally = can do very little, up to 1/3 of day (up to about 2 hours in 8-hr. day) Frequently = can do about 2/3 of day (about 6 hours in 8-hr. day) SSR 96-9p 74 Exertional Demands of Work – 20 CFR 416.967 Sedentary Light Medium Heavy 75 Physical Demands of Full Range of Sedentary Work Lifting no more than 10 pounds at a time and occasionally to lift or carry articles like docket files, ledgers, and small tools. Occasional walking and standing (no more than about 2 hours of an 8-hr. workday). Sitting about 6 hours of an 8-hour workday. 20 CFR 416.967(a) 76 Mental RFC Components 20CFR 416.945(c) Nonexertional Activities: Concentrating Remembering Understanding Carrying out simple instructions Responding appropriately to supervision Getting along with co-workers 77 Step 5 Considerations Final step in the sequential analysis Considers whether the individual can perform other work in the economy SSA uses “Grids” for exertional impairments Individual analysis required for solely or significant non-exertional impairments. 78 Step 5 Factors Residual functional capacity (mental and physical, exertional and nonexertional) Age, 20 CFR 416.963 Education, 20 CFR 416.964 Past relevant work experience, 20CFR416.967 - strength requirements - skill level Transferable skills, 20 CFR 416.968 Ability to Communicate in English (Step 5 only) 79 Step 5 Evidence Issues 20 CFR 416.960(c) If past work precluded, SSA has burden to prove there is other work available in significant numbers in national economy that claimant could do considering RFC, age, education & transferable work skills. SSA usually needs vocational expert to testify to jobs available and skill level and physical and mental demands of these jobs. 80 Step 5 Evidence Issues BUT, claimant’s burden to prove claimant’s RFC, age, education, work skills, and other vocational limitations that erode the occupational base. ALJ weighs evidence and determines claimant’s RFC and other vocational limitations. ALJ then matches RFC and vocational limitations with jobs identified by vocational expert. 81 Basic Mental Demands of Competitive Work These mental activities are generally required by competitive, remunerative, unskilled work: Understanding, remembering, and carrying out simple instructions. Making judgments that are commensurate with the functions of unskilled work--i.e., simple work- related decisions. Responding appropriately to supervision, co- workers and usual work situations. Dealing with changes in a routine work setting. SSR 96-9p, SSR 85-15, SSR 85-16 82 Basic Mental Demands of Competitive Work - Continued A substantial loss of ability to meet any one of several basic work-related mental activities on a sustained basis will substantially erode the unskilled sedentary occupational base and would justify a finding of disability. SSR 96-9p 83 Stress No such thing as a “low stress job.” Stress “is not a job characteristic, but rather, reflects an individual’s subjective response to particular situation.” Lancellotta v. Secy HHS, 806 F.2d 284 (1st Cir. 1986). SSR 85-15 Need individualized inquiry into what job attributes are likely to produce stress in the claimant and whether jobs exist in the economy that do not possess these attributes. 84 Pain 20 CFR 416.929 Pain can cause both exertional and nonexertional RFC limitations (e.g., inability to sit & problems concentrating). Must be medically determinable impairment, established using medically acceptable clinical and laboratory diagnostic techniques, that can reasonably be expected to produce the pain alleged. Avery v. Secy HHS, 797 F.2d 19 (1st Cir.1986). Also SSR 96-3p, 96-4p 85 Pain - continued If the severity of the pain alleged is greater than indicated by the objective medical evidence, ALJ must then consider all the available evidence, medical and other, that reflects on the impairment and resulting limitations of function. "Other" evidence that may be used to show the severity of pain includes chiropractors, as well as "lay" sources, like family & friends, employers, counselors, etc. 86 Summary - Step Five Individualized Determination Analysis If there other work in significant numbers in the economy that the claimant can do considering her RFC, age, education, work history and ability to communicate in English? Bottom Line – Does claimant have mental and physical RFC to do a sedentary unskilled job on a regular and continuing basis? 87 Drug Abuse and Alcoholism (DAA) eliminated DAA as a basis of disability eligibility for SSI and SSDI when DAA is “material” to the disability determination. Effective 3/29/96 for new applications; 1/1/97 for those on benefits. Does not automatically disqualify people with a substance abuse history or current habit, or people with disabilities caused by DAA (e.g., organic brain damage, liver disease). 88 Disability Analysis for DAA EM-96200 Step 1 - Is claimant disabled, considering all impairments, including any DAA? Step 2 - Is there medical evidence of a DAA condition? Step 3 - Is DAA material to the disability determination? I.E. Would the claimant still be disabled without consideration of DAA impairments and limitations? 89 Definition of Disability for Children The child must have a medically determinable physical or mental impairment or combination of impairments that results in marked and severe functional limitations and which can be expected to last in death or which has lasted or can be expected to last for at least 12 months. 90 Disability Analysis for Children (1) Medical (MD) documentation of mental and/or physical conditions or illness, That have lasted or expected to last at least one year, and That result in marked and severe limitations in age appropriate function (mental and/or physical) 91 Sequential Disability Analysis for Children Is the child performing SGA? Does the child have an impairment or combination of impairments that are more than non-severe (de minimis test)? Do the child’s impairments meet or equal the severity of a listed impairment? medically meet a listed impairment? medical equivalence to a listed impairment? or functional equivalence to the listings. 92 Children’s Listed Impairments Does the child's condition manifest the specific findings described in the medical and functional criteria of one of the SSA listed impairments? Example - 107.05 Sickle cell disease. With: A. Recent, recurrent severe vaso-occlusive crises; or B. A major visceral complication in the 12 months prior to application; or C. A hyperhemolytic or aplastic crisis within 12 months prior to application; or D. Chronic, severe anemia with persistence of hernatocrit of 26 percent or less; or E. Congestive heart failure, cerebrovascular damage, or emotional disorder as described under the criteria in 104.02, 111.00ff, or 112.00ff. 93 Domains of Function for Functional Equivalence Acquiring and using information Attending and completing tasks Interacting and relating with others Caring for oneself Moving about and manipulating objects Health and physical well-being See SSRs 09-1p – 09-8p 94 Severity Level Required Eligibility requires marked level functional limitations in 2 domains or extreme functional limitation in 1 domain. “Marked” means that the impairment(s) seriously affect the child’s ability to function in a domain. “Extreme” means that the impairment(s) very seriously affect the child’s ability to function in a domain. 95 Other Factors to Consider Symptoms such such as pain, fatigue, decreased energy, anxiety; Age appropriate functioning; Combined effects of multiple impairments Ability to initiate, sustain and complete activities; Amount of help or adaptations needed; Effects of structured or supportive settings; 96 Other Factors to Consider Unusual settings, i,e. testing settings; Participation in early intervention and other school programs; Impact of chronic illness and limitations that interfere with activities over time; Effects of treatment, including medications and therapies. 97 Proving Your Case – Evidence Issues To establish a diagnosis, need evidence from acceptable medical source: BUT other evidence, especially from professional sources is very important, especially as to nature & severity of functional limitations. 20 CFR 416.913 98 Treating Physician Rule 20 CFR 416.927 If medical opinion is from acceptable treating source (M.D. or Ph.D.), and Opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques, and Opinion is not inconsistent with other substantial evidence in the record Then, treating source opinion is given controlling weight. 99 Evidence Issues – Cont. Other Sources of Evidence: Therapists Nurse practitioners Teachers Early intervention providers Counselors Rehabilitation specialists Lay sources: Family, friends 100 Evidence Issues: The Bottom Line All evidence should be considered and weighed. Weight given depends on Credibility, and Support. 20 CFR 416.913, .927, SSR 06-3p 101 Provider Role in Disability Determinations Providers are an important resource in the disability determination process. Provider information is necessary to establish a diagnosis. Provider information is also key in establishing the degree of disability, i.e., the severity of functional limitations. 102 Where Providers Go Wrong on Disability Determinations Do not respond (timely or at all) Do not understand their role (information provider – not the decision maker) Do not understand the SSA standard (e.g. say patient can do sedentary work without knowing SSA definition of term) 103 Where Providers Go Wrong on Disability Determinations Respond without enough knowledge of the facts (e.g., how pain affects daily life of patient) Respond as to other clinicians – and SSA does not fully understand the import Do not document functional limitations 104 Where Providers Go Wrong on Disability Determinations Say “patient doing well” without explaining the specific circumstances of the patient, e.g., is “well under the circumstances” what is meant ? Do not fully document symptoms such as pain and fatigue. 105 Age 18 Redeterminations Children must be redetermined under the adult disability standard within one year from the date they attain age 18. SSA will notify a recipient that a review has begun and will invite the recipient to submit evidence of continuing disability. This NOT a CDR – it is a determination as to whether the young person is eligible under the adult disability standard. 106 Other Reviews of Eligibility for Benefits Continuing Disability Reviews: SSA must review disability eligibility of most SSI/DI recipients at least every 3 years. Recipients deemed likely to medically improve may be reviewed more frequently. Recipients deemed permanently disabled are reviewed less frequently, usually every 7 yrs. 107 CDR Standard for Adults Has there been medical improvement in the impairment(s) present when benefits approved? If no, benefits continue. If yes… Is medical improvement related to the ability to work? Compare RFC now with RFC at time of approval. If no, benefits continue. If yes… Does the person meet the disability eligibility standard, considering current impairments? BUT – benefits can be terminated if fraud, noncooperation with review, inability to locate, failure to follow prescribed treatment. 108 CDR Standard for Children Under 18 Same as for adults except does not consider the ability to work and does not include a functional capacity assessment below the severity level of the listings of impairments listings level, i.e., one “extreme” or two “marked”- level limitations in areas of function. 109 CDR and Age 18 Review Appeal Process Terminations are appealable and continuing benefits available through ALJ hearing if appeal filed within 10 days and continuing benefits requested at each step of appeal. Otherwise, appeal period is 60 days. If lose on appeal, no collection overpayment if good faith belief that individual was still disabled and eligible for benefits and cooperated with the process. Must file Request for Waiver form. 110 SSI Nondisability Eligibility Review Is recipient still eligible for SSI and getting the correct amount of SSI considering: Financial eligibility – income, resources Living arrangement Immigration status Periodically scheduled according to likelihood of error; unscheduled based on information received. 111 SSA’s Administrative Appeals Process In Massachusetts and the other N.E. states, the administrative appeals process is in a state of flux. SSA has been trying out a revised administrative appeals process for certain cases. Disability Service Improvements (DSI). 112 SSA’s Administrative Appeal Process Levels of appeal: Reconsideration -to appeal application decision Administrative Law Judge (ALJ) Hearing - to appeal Reconsideration Appeals Council Review - to appeal ALJ decision Federal Court 20 CFR 404.900 et seq., 416.1400 et seq. 113 DSI Appeals Process Applies to only to initial disability applications filed in the N.E. states on or after 8/1/2006. Does not apply to initial disability applications filed before 8/1/2006 or filed in other states, even if the applicant moves into a DSI state. Does not apply to cases other than initial disability applications. 114 DSI Appeals Process 20 CFR 405.000 et seq. Federal Reviewing Official (FedRO) – suspended for new appeals eff. 3/23/08. Reconsideration reinstated. ALJ hearing – includes restrictive evidence submission rules. 20 CFR 405.331 Decision Review Board (DRB) – no claimant right of appeal. Reviewed ALJ decisions pre effectuation. 90 days to complete review. DRB eliminated eff. 6/13/11. Appeals Council reinstated. HALLEX Rule I-5-3-18 Federal Court 115 What’s Left of DSI? Some differences at ALJ level 75 day advance notice 5 business day pre hearing evidence rule, with restrictive rules for later submissions Some differences in timing of other requests Some differences at the AC Record closed after ALJ decision New restrictions on submitting evidence at AC Final Regs-76 Fed. Reg. 24802 (5/3/11) 116 What’s Left of DSI? continued ALJ DSI Rules – 20 CFR 405.301 – 405.383, as pub’d at 76 Fed. Reg. 24802 (5/3/11). Appeals Council DSI Rules – 20 CFR 405.401 - .510, as pub’d at 76 Fed. Reg. 24802. These differences apply only to initial disability applications filed after 8/1/06 in a N.E. state. The rules at 20 CFR 404.900 et seq., 416.1400 et seq., in non-DSI cases. 117 Appeals - Time 60-day deadline for filing appeals; SSA assumes notices received within 5 days of date on notice. Can get aid pending appeal if request it and file within 10 days of receipt of notice if SSI termination, reduction or suspension; medical termination of SSI/DI after CDR. For CDRs can also get aid pending through ALJ level appeal. 118 Appeals - continued Good cause (really good reason) for late filing an appeal. POMS DI 03101.020 File appeals online at local SSA office; get date stamped and keep copy. Appeal forms online at www.socialsecurity.gov/online/forms 119 Useful Websites www.socialsecurity.gov www.mass.gov/MassHealth www.masslegalservices.org www.cms.hhs.gov/home/medicare.asp 120
"SSI and SSDI Basics - Mass Legal Services"